Looking Behind the Curtain: Identifying Factors Contributing to Changes on Care Outcomes During a Large Commercial EHR Implementation

Abstract

Objective: To identify factors contributing to changes on quality, productivity, and safety outcomes during a large commercial electronic health record (EHR) implementation and to guide future research. Methods: We conducted a mixed-methods study assessing the impact of a commercial EHR implementation. The method consisted of a quantitative longitudinal evaluation followed by qualitative semi-structured, in-depth interviews with clinical employees from the same implementation. Fourteen interviews were recorded and transcribed. Three authors independently coded interview narratives and via consensus identified factors contributing to changes on 15 outcomes of quality, productivity, and safety. Results: We identified 14 factors that potentially affected the outcomes previously monitored. Our findings demonstrate that several factors related to the implementation (e.g., incomplete data migration), partially related (e.g., intentional decrease in volume of work), and not related (e.g., health insurance changes) may affect outcomes in different ways. Discussion: This is the first study to investigate factors contributing to changes on a broad set of quality, productivity, and safety outcomes during an EHR implementation guided by the results of a large longitudinal evaluation. The diversity of factors identified indicates that the need for organizational adaptation to take full advantage of new technologies is as important for health care as it is for other services sectors. Conclusions: We recommend continuous identification and monitoring of these factors in future evaluations to hopefully increase our understanding of the full impact of health information technology interventions.

An Evaluation of System End-User Support during Implementation of an Electronic Health Record Using the Model for Improvement Framework

“…They noted that the number of people allocated for implementation support could be a covariate and/or a moderator and impact clinicians' efficiency post-go-live, potentially contributing to longer lengths of stay, increased wait times, and a lower volume of visits. 7 A common theme in the literature emphasizes the need for providing on-site support during implementation and is seen as a critical factor to effective adoption. 4,5,[7][8][9][10][11][12] Using the model for improvement, endorsed by the Institute for Healthcare Improvement as a framework, this case report will describe the activities that follow the planning, doing, studying, and acting of providing on-site support to clinicians and other system end-users at Vanderbilt University Medical Center (VUMC) during a recent EHR implementation.…”

Twilighted Homegrown Systems: The Experience of Six Traditional Electronic Health Record Developers in the Post–Meaningful Use Era

“…48 It is true that achieving nationwide adoption by relying primarily on homegrown systems would likely be unattainable, as the infrastructure needed to share functionality developed locally is still under development. 49,50 However, it is also true that the expected benefits of a digital health system 51 have not yet materialized through commercial EHR adoption [52][53][54][55][56] ; 4 years after becoming a commercially based digital health system, the U.S. health system continues to be the most expensive and lags behind other developed countries in some quality outcomes. 56 The collective experience of the surveyed organizations indicates that while the migration to a commercial system may facilitate implementation or maintenance of terminology and knowledge management solutions, it also introduces important gaps.…”

Unintended Consequences of Nationwide Electronic Health Record Adoption: Challenges and Opportunities in the Post-Meaningful Use Era

“…Furthermore, studies from other industries demonstrate that IT adoption rarely produces positive results if not accompanied by complementary factors or investments [16]. Several internal and external factors have been identified as potentially affecting care outcomes during HIT interventions [17], which suggests that previous studies may have been subjected to similar context-dependent factors, as they are common to HIT interventions [18,19]. Pre-MU studies are being criticized for relying on weak research designs such as short-term pretest-posttests and for the use of a small set of nonconsensus measurements [8,12,20].…”

“…A paradigm shift on the choice of research designs for HIT studies is needed to produce more longitudinal evaluations able to detect time-sensitive effects common to HIT interventions [26] and to assess a large set of measures capable of detecting the diverse effects of such interventions [11,12]. Furthermore, as HIT interventions are subject to context-dependent factors, assessment of potential covariates is of paramount importance, as demonstrated elsewhere [17]. A better understanding of the full impact of HIT on the US health system will demand more comprehensive evaluations that assess a large sample of agreed-upon measures shared across researchers to allow comparison of outcomes across studies by future systematic reviews—and potential meta-analyses.…”

“…Recent studies have found that in the post-MU and ACA era, for every hour of patient contact time, physicians may spend up to 2 hours on electronic documentation [53,54]. The documentation burden has been so intense that in some cases, physicians intentionally close slots in their agenda to complete electronic documentation of previous patients [17].…”